Provider Demographics
NPI:1548335326
Name:UDOVICH, CHRISTOPHER WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:WILLIAM
Last Name:UDOVICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21205 OWENS RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2023
Mailing Address - Country:US
Mailing Address - Phone:815-469-2123
Mailing Address - Fax:815-469-2149
Practice Address - Street 1:21205 OWENS RD STE 3
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-2023
Practice Address - Country:US
Practice Address - Phone:815-469-2123
Practice Address - Fax:815-469-2149
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102980Medicaid
IL09915014OtherBLUE CROSS BLUE SHIELD
649420OtherMEDICARE PROV NUMBER
IL09915014OtherBLUE CROSS BLUE SHIELD